Hematology Practice Questions

Q: A 55-year-old male with fatigue and a palpable spleen is found to have a high white cell count predominantly consisting of mature lymphocytes. What is the most likely diagnosis?

Chronic lymphocytic leukemia. ***Chronic lymphocytic leukemia*** - The presence of **fatigue**, a **palpable spleen**, and an elevated white cell count predominantly consisting of **mature lymphocytes** is highly characteristic of CLL [1]. - CLL is a common leukemia in older adults, where **monoclonal B-lymphocytes** accumulate in the blood, bone marrow, and lymphoid organs [1]. *Acute lymphoblastic leukemia* - This leukemia typically presents with **immature lymphocytes (blasts)** and a more aggressive clinical course, often seen in children [2]. - While it causes fatigue and can lead to organomegaly, the predominance of **mature lymphocytes** in the peripheral blood rules out ALL [2]. *Myelodysplastic syndrome (ineffective hematopoiesis and cytopenias)* - This syndrome is characterized by **ineffective hematopoiesis** and **cytopenias** (low blood cell counts), rather than a high white cell count. - It involves dysplasia in one or more myeloid cell lines, and the peripheral smear would show abnormal cell morphology, not a predominance of mature lymphocytes. *Hairy cell leukemia (characterized by "hairy" appearing cells)* - While it presents with **splenomegaly** and can cause fatigue, the characteristic cells have **"hairy" cytoplasmic projections** and are rarely found in high numbers in the peripheral blood initially. - The diagnosis is confirmed by flow cytometry and bone marrow biopsy, and the classic picture often includes **pancytopenia**, not just a high white cell count from mature lymphocytes.

Q: In anemia of chronic disease, which iron parameter is typically elevated?

Ferritin. ***Ferritin*** - In **anemia of chronic disease (ACD)**, inflammation leads to increased production of **hepcidin**, which blocks iron release from stores [1]. - As a result, iron is trapped within macrophages and liver cells, causing **elevated ferritin levels**, which reflects increased iron stores despite functional iron deficiency. *Serum iron* - **Serum iron** levels are typically **decreased** in ACD because hepcidin inhibits iron absorption from the gut and release from macrophages [1]. - This reduction in circulating iron contributes to the anemia, as less iron is available for erythropoiesis. *Total iron-binding capacity* - **Total iron-binding capacity (TIBC)**, which primarily reflects **transferrin levels**, is usually **decreased** or normal in ACD [2]. - This is in contrast to iron deficiency anemia, where transferrin production increases to try and capture more iron. *Transferrin* - **Transferrin levels** are typically **decreased** or normal in ACD due to inflammation's suppressive effect on liver protein synthesis. - Reduced transferrin contributes to the decreased TIBC and further limits the transport of iron to erythroid precursors.

Q: A 50-year-old male presents with fatigue and pallor. His peripheral smear shows hypersegmented neutrophils and macro-ovalocytes. What is the most likely diagnosis?

Folate deficiency anemia. ***Folate deficiency anemia*** - The presence of **hypersegmented neutrophils** and **macro-ovalocytes** on peripheral smear is characteristic of **megaloblastic anemia**, which can be caused by folate deficiency. - **Fatigue** and **pallor** are common symptoms of anemia. *Iron deficiency anemia* - This typically presents with **microcytic, hypochromic** red blood cells, which is contrary to the macro-ovalocytes seen in this patient. - Iron deficiency does not cause **hypersegmented neutrophils**. *Thalassemia* - Thalassemia usually causes **microcytic, hypochromic anemia** and is characterized by abnormal hemoglobin production. - It does not involve **hypersegmented neutrophils** or **macro-ovalocytes**. *Chronic myeloid leukemia* - This condition is characterized by an overproduction of **granulocytes**, often with a **left shift** in the myeloid lineage. - It does not typically present with **hypersegmented neutrophils** and **macro-ovalocytes** as the primary diagnostic features.

Q: A 50-year-old man presents with fatigue and dizziness. Blood work shows normocytic anemia with elevated ferritin levels. Genetic testing reveals a homozygous HFE mutation. What is the best treatment option for this condition?

Phlebotomy is the best treatment option.. PHLEBOTOMY IS THE BEST TREATMENT OPTION. - The patient's presentation with **fatigue, dizziness, normocytic anemia, elevated ferritin**, and a **homozygous HFE mutation** strongly suggests **hereditary hemochromatosis**. [1], [2] - **Phlebotomy** is the first-line treatment as it directly removes excess iron from the body by drawing blood, preventing organ damage. [1] *Transfusion with packed RBCs is recommended.* - **Transfusions** would further increase iron levels in a patient with **iron overload**, exacerbating the condition and potentially causing more harm. - This treatment is appropriate for severe symptomatic anemia due to **iron deficiency** or other causes, not iron overload. *Chelation therapy with deferoxamine is indicated.* - **Chelation therapy** is used for iron overload when phlebotomy is contraindicated (e.g., severe anemia, poor venous access) or ineffective. - While effective, **deferoxamine** is typically a second-line therapy for hereditary hemochromatosis, as phlebotomy is generally safer and more efficient. *High-dose corticosteroids should be used.* - **Corticosteroids** are anti-inflammatory and immunosuppressive agents, primarily used for autoimmune conditions or certain types of anemia (e.g., autoimmune hemolytic anemia). - They have **no role** in the treatment of **hereditary hemochromatosis** or iron overload.

Q: A 60-year-old man presents with fatigue, weight loss, and bone pain. Laboratory tests reveal anemia, hypercalcemia, and renal insufficiency. What is the most likely diagnosis?

Multiple myeloma. ***Multiple myeloma*** - The constellation of **fatigue (due to anemia)**, **weight loss**, **bone pain**, **hypercalcemia**, and **renal insufficiency** is characteristic of multiple myeloma, often described by the mnemonic **CRAB criteria** (Calcium elevation, Renal failure, Anemia, Bone lesions) [1, 2]. - This plasma cell malignancy leads to overproduction of **monoclonal immunoglobulins** (M-proteins) which can cause kidney damage, and osteolytic lesions leading to bone pain and hypercalcemia [1, 2]. *Chronic lymphocytic leukemia* - While it can present with fatigue and weight loss, specific features like **bone pain**, **hypercalcemia**, and **renal insufficiency** are not typical primary manifestations. [3] - Diagnosis usually involves **lymphocytosis** and the presence of **clonal B-cells** with specific immunophenotypes. *Non-Hodgkin lymphoma* - Patients often present with **lymphadenopathy**, **fever**, **night sweats**, and **weight loss**, but **hypercalcemia** and **renal insufficiency** due to direct bone involvement or myeloma kidney are less common. - Bone pain might occur if there's extensive **bone marrow involvement**, but it's not the primary feature compared to myeloma. *Primary hyperparathyroidism* - This condition primarily causes **hypercalcemia** and can lead to **bone pain** (osteitis fibrosa cystica) and **renal stones/insufficiency**. - However, **anemia** and significant **weight loss** are not typical presenting features; severe anemia is more indicative of a hematologic malignancy.

Q: A beta-thalassemia patient was given 125 units of packed red blood cells. Which additional drug should be administered?

Desferroxamine. ***Desferroxamine*** - Patients with **beta-thalassemia** often require frequent **packed red blood cell transfusions** to manage severe anemia. - These transfusions lead to **iron overload** (hemosiderosis), necessitating iron chelation therapy with drugs like **Desferroxamine** to prevent organ damage. *Cytarabine* - **Cytarabine** is a **chemotherapeutic agent** primarily used in the treatment of various leukemias, particularly **acute myeloid leukemia**. - It is not indicated for the management of **iron overload** in thalassemia patients. *Hydroxyurea* - **Hydroxyurea** is used to increase **fetal hemoglobin** production in conditions like **sickle cell anemia** and some forms of beta-thalassemia [1]. - While it can reduce transfusion requirements in some thalassemia patients, its primary role is not to address **iron overload** already caused by transfusions. *Butyrates* - **Butyrates** are being investigated for their potential to induce **fetal hemoglobin** production, similar to hydroxyurea, in hemoglobinopathies. - They do not directly address **iron overload** and are not standard therapy for this complication.

Q: Which of the following is a significant risk factor for developing deep vein thrombosis (DVT)?

Recent surgery. **Recent surgery** - **Surgical procedures**, especially orthopedic surgeries (e.g., hip or knee replacement), cause **endothelial injury** and activate the coagulation cascade [3]. - The **postoperative period** is associated with reduced mobility and systemic inflammatory responses, significantly increasing the risk of **venous stasis** and **hypercoagulability** [2]. *Long periods of immobility* - While immobility is a significant contributor to DVT, it is a broader category of risk. **Recent surgery** often combines immobility with additional risk factors like tissue trauma and inflammation, making it a more specific and acute risk factor [2]. - **Venous stasis** due to immobility allows clotting factors to accumulate, promoting clot formation. *Use of oral contraceptives* - **Estrogen-containing oral contraceptives** increase the synthesis of clotting factors and decrease natural anticoagulants, leading to a **hypercoagulable state**. - While a risk factor, it is often a chronic predisposition rather than an acute precipitating factor like recent surgery. *Advanced age* - **Advanced age** is associated with an increased risk of DVT due to age-related changes in the coagulation system, endothelial function, and higher prevalence of comorbidities [1], [4]. - However, it is a general predisposing factor, whereas **recent surgery** represents a more immediate and potent trigger.

Q: A 40-year-old woman presents with fatigue and pallor. A peripheral blood smear shows hypochromic microcytic anemia. She has a history of heavy menstrual bleeding. What is the most likely cause of her anemia?

Iron deficiency anemia. ***Iron deficiency anemia*** - The patient's **heavy menstrual bleeding** likely leads to **iron loss**, causing hypochromic microcytic anemia [1][2]. - The peripheral blood smear findings are characteristic of **iron deficiency**, which is the most common cause of anemia in women of reproductive age [1][2]. *Vitamin B12 deficiency* - Typically presents with **macrocytic anemia** and neurological symptoms, which are absent in this patient. - Blood smear would show **megaloblasts** rather than hypochromic microcytic cells. *Thalassemia minor* - Although it can cause **microcytic anemia**, it usually does not present with significant **fatigue** or **pallor** without a family history. - It is typically associated with an elevated **HbA2** level found in hemoglobin electrophoresis, which is not indicated here. *Sideroblastic anemia* - Characterized by the presence of **ringed sideroblasts** in the bone marrow, not typically seen in a peripheral smear. - It often presents with **microcytic anemia**, but causes are often related to **congenital disorders** or certain **toxins** rather than heavy menstrual bleeding.

Question 1

A 55-year-old male with fatigue and a palpable spleen is found to have a high white cell count predominantly consisting of mature lymphocytes. What is the most likely diagnosis?

Accepted Answer

Chronic lymphocytic leukemia

Answer

Acute lymphoblastic leukemia

Answer

Myelodysplastic syndrome (ineffective hematopoiesis and cytopenias)

Answer

Hairy cell leukemia (characterized by "hairy" appearing cells)

Question 2

In anemia of chronic disease, which iron parameter is typically elevated?

Accepted Answer

Ferritin

Answer

Serum iron

Answer

Total iron-binding capacity

Answer

Transferrin

Question 3

A 50-year-old male presents with fatigue and pallor. His peripheral smear shows hypersegmented neutrophils and macro-ovalocytes. What is the most likely diagnosis?

Accepted Answer

Folate deficiency anemia

Answer

Iron deficiency anemia

Answer

Thalassemia

Answer

Chronic myeloid leukemia

Question 4

A 54-year-old male presents with fever, confusion, and petechiae. Laboratory results show decreased platelets, increased PT/INR, increased D-dimer, and decreased fibrinogen. Analyze and determine the diagnosis and appropriate initial management.

Accepted Answer

Disseminated intravascular coagulation; treat underlying cause

Answer

Thrombocytopenic purpura; plasma exchange

Answer

Sepsis; broad-spectrum antibiotics

Answer

ITP; corticosteroids

Question 5

Which of the following conditions is not associated with venous and arterial thrombotic events?

Accepted Answer

Idiopathic Thrombocytopenic Purpura (ITP), a condition primarily causing bleeding.

Answer

Heparin-Induced Thrombocytopenia (HIT), a condition associated with immune-mediated thrombosis.

Answer

Paroxysmal Nocturnal Hemoglobinuria (PNH), a condition linked to hemolysis and thrombosis.

Answer

Disseminated Intravascular Coagulation (DIC), a condition involving widespread clotting and bleeding.

Question 6

A 50-year-old man presents with fatigue and dizziness. Blood work shows normocytic anemia with elevated ferritin levels. Genetic testing reveals a homozygous HFE mutation. What is the best treatment option for this condition?

Accepted Answer

Phlebotomy is the best treatment option.

Answer

Transfusion with packed RBCs is recommended.

Answer

Chelation therapy with deferoxamine is indicated.

Answer

High-dose corticosteroids should be used.

Question 7

A 60-year-old man presents with fatigue, weight loss, and bone pain. Laboratory tests reveal anemia, hypercalcemia, and renal insufficiency. What is the most likely diagnosis?

Accepted Answer

Multiple myeloma

Answer

Chronic lymphocytic leukemia

Answer

Non-Hodgkin lymphoma

Answer

Primary hyperparathyroidism

Question 8

A beta-thalassemia patient was given 125 units of packed red blood cells. Which additional drug should be administered?

Accepted Answer

Desferroxamine

Answer

Cytarabine

Answer

Hydroxyurea

Answer

Butyrates

Question 9

Which of the following is a significant risk factor for developing deep vein thrombosis (DVT)?

Accepted Answer

Recent surgery

Answer

Advanced age

Answer

Use of oral contraceptives

Answer

Long periods of immobility

Question 10

A 40-year-old woman presents with fatigue and pallor. A peripheral blood smear shows hypochromic microcytic anemia. She has a history of heavy menstrual bleeding. What is the most likely cause of her anemia?

Accepted Answer

Iron deficiency anemia

Answer

Thalassemia minor

Answer

Sideroblastic anemia

Answer

Vitamin B12 deficiency

Hematology — MCQs

Hematology — MCQs

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